Primary prevention

Primary prevention can be via passive immunisation with hepatitis B immunoglobulin (HBIG) or via active immunisation with hepatitis B vaccine (recombinant inactive hepatitis B surface antigen [HBsAg]).

Infants, children, and adolescents ≤18 years

  • The World Health Organization recommends that all infants should receive a hepatitis B vaccine series, with the first dose given as soon as possible after birth, preferably within 24 hours, followed by two or three doses administered according to national routine immunisation schedules.​[64]​​

    • The monovalent vaccine should be used for the birth dose, while monovalent or combined vaccines can be used in infants aged >6 weeks.

  • In the US, the Advisory Committee on Immunization Practices (ACIP) recommends babies receive a first dose of hepatitis B vaccine within 24 hours of birth, with a second dose at 1-2 months (minimum interval after first dose of 4 weeks), and a third dose at 6-18 months (at least 8 weeks after the second dose and at least 16 weeks after the first dose). If no dose is given at birth, then three doses of a hepatitis B-containing vaccine should be given on a schedule of 0, 1-2, and 6 months, starting as soon as possible. A four-dose series is permitted when a combination vaccine containing hepatitis B is administered after the birth dose. The final (third or fourth) dose should be administered no earlier than the age of 24 weeks. The monovalent vaccine should be used for doses administered before age 6 weeks.[65]​​​

    • Babies born to HBsAg-positive mothers should receive both hepatitis B vaccine (monovalent vaccine only) and HBIG (in separate limbs) within 12 hours of birth, regardless of birth weight. Babies <2000 g should receive three additional doses of vaccine (total of four doses), beginning at age 1 month. Babies should be tested for HBsAg and antibody to hepatitis B surface antigen at age 9-12 months, or if vaccination is delayed, at 1-2 months after completion of hepatitis B vaccine series.

    • Babies born to mothers with an unknown HBsAg status should receive hepatitis B vaccine within 12 hours of birth regardless of birth weight, and those weighing <2000 g should also receive HBIG (in separate limbs) and three additional doses of vaccine (total of four doses), beginning at age 1 month. For babies weighing ≥2000 g, the mother’s HBsAg status should be determined as soon as possible and, if positive, HBIG given to the baby as soon as possible and within 7 days. If there is evidence to suggest maternal hepatitis B infection, manage infants as if the mother is HBsAg-positive.

    • Babies born to HBsAg-negative mothers should receive one dose of hepatitis B vaccine within 24 hours of birth if medically stable and birth weight is ≥2000 g. Babies <2000 g should receive one dose at chronological age 1 month or hospital discharge (whichever is earlier, even if weight is still <2000 g).

    • Catch-up vaccination: children and adolescents who have not previously received the hepatitis B vaccine should receive the standard schedule of three vaccinations at 0, 1-2, and 6 months. Adolescents aged 11-15 years may receive an alternative two-dose series of adult Recombivax HB® with at least 4 months between doses. Adolescents aged ≥18 years may receive a two-dose series of Heplisav-B® at least 4 weeks apart, a three-dose series of PreHevbrio® at 0, 1, and 6 months, or the combined hepatitis A and hepatitis B vaccine (Twinrix®) as a three- or four-dose series.

  • The American College of Obstetricians and Gynecologists (ACOG) supports the recommendation that neonates of HBsAg-positive mothers (or whose status is unknown at the time of delivery), receive both hepatitis B vaccination and HBIG within 12 hours of birth.[66]

  • In the UK, the routine childhood immunisation programme includes hepatitis B in the combination vaccine for diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type B (DTaP/IPV/Hib/HepB).[67]

    • Vaccination with DTaP/IPV/Hib/HepB is recommended at aged 8, 12, and 16 weeks, but can be given from age 6 weeks to 10 years.

    • Babies born to hepatitis B-infected mothers should receive a monovalent hepatitis B vaccine at birth (within 24 hours) and at 4 weeks, followed by multivalent vaccine at 8, 12, and 16 weeks; babies are tested for HBsAg at one year of age and given a further dose of monovalent hepatitis B vaccine.

    • Babies born to hepatitis B-infected mothers should also receive HBIG within 24 hours of the birth dose of the hepatitis B vaccine and within 7 days following birth, unless the mother is HBsAg-positive and anti-HBe-positive and HBeAg negative, or the mother is HBsAg positive and the baby also weighs >1500 g at birth.

    • Children aged under 10 years of age who have completed their course of immunisations for diphtheria, tetanus, pertussis and polio, but have not received hepatitis B vaccination should opportunistically be offered a hepatitis B vaccine course, while those who are exposed to hepatitis B or who are in a high-risk group should proactively be offered a hepatitis B vaccine course.

    • Consult the UK immunisation schedule for more detailed information on hepatitis B vaccination.

  • The global coverage with the third dose of hepatitis B vaccine was between 82% and 85% between 2016 and 2020. Coverage was ≥90% for both the birth dose and the 3-dose series in 41% of countries with data available in 2020.[17]

  • Immunisation schedules differ between countries. Consult your local immunisation protocols for more information.

Adults

  • In the US, ACIP recommends universal vaccination in adults aged 19-59 years with a two-, three-, or four-dose series. Adults ≥60 years of age with known risk factors for infection (see below) should receive a complete vaccine series. Adults ≥60 years of age without known risk factors may receive a complete vaccine series if they choose to or request it. The dose schedule depends on the vaccine used (e.g., Engerix-B®, Recombivax HB®, Heplisav-B®, Twinrix®, PreHevbrio®). Consult the immunisation schedule for more detailed information. Adults ≥60 years of age with diabetes should receive vaccination based on shared clinical decision-making.[68]​​​

  • At-risk populations include:

    • People with chronic liver disease (e.g., hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase or aspartate aminotransferase level greater than twice upper limit of normal)

    • People with HIV infection or current or recent injection drug use

    • People with a sexual exposure risk (e.g., sex partners of HBsAg-positive people, sexually active people not in mutually monogamous relationships, men who have sex with men, people seeking evaluation or treatment of sexually transmitted infection)

    • People with percutaneous or mucosal risk for exposure to blood (e.g., patients with diabetes, dialysis patients, household contacts of HBsAg-positive people, healthcare personnel)

    • Incarcerated people

    • People traveling to countries with high or intermediate endemic hepatitis B.

  • ACOG supports the use of the hepatitis B vaccine with an appropriate vaccine during pregnancy for recommended patient groups.[66]

  • In the UK, an accelerated schedule is given in most risk groups, with the vaccine given at 0, 1, 2, and 12 months, or alternatively, at 0, 1, and 6 months where rapid protection isn’t required and adherence is likely.​[67]​ Consult the UK immunisation schedule for more detailed information on hepatitis B vaccination.

  • Immunisation schedules differ between countries. Consult your local immunisation protocols for more information.

Secondary prevention

The following secondary prevention measures are recommended:[2][38]

  • Screen pregnant women for hepatitis B surface antigen (HBsAg). Pregnant women should also be encouraged to discuss the need for maternal antiviral therapy, as well as newborn hepatitis B vaccination and hepatitis B immunoglobulin (HBIG), with their obstetrician to prevent mother-to-child transmission.

  • Advise healthcare workers with HBV infection who perform exposure-prone procedures to seek counselling and advice from an expert review panel, as antiviral prophylaxis may be recommended.

  • Initiate antiviral prophylaxis in patients who are starting on immunosuppressive therapy (including chemotherapy or immunotherapy) to prevent hepatitis B reactivation.

  • Initiate lifelong antiviral prophylaxis with a nucleoside/nucleotide analogue (with or without HBIG) in all HBsAg-positive patients undergoing liver transplantation, regardless of pre-transplant hepatitis B e antigen status, or HBV DNA level. An individualised approach to HBIG use is recommended.

  • Initiate long-term antiviral therapy in HBsAg-negative patients receiving livers from donors with evidence of past HBV infection (antibody to hepatitis B core antigen-positive) to prevent HBV reactivation.

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